CODING & DOCUMENTATION

Hospital admission and discharge

Q

This morning I provided initial hospital care for a patient who was treated in the emergency department (ED) yesterday evening by another physician. This afternoon, I decided that the patient was ready to be discharged and sent him home. How should I bill for my services? If the patient had been admitted and discharged on the same date, I would have billed an admission/discharge code (99234-99236); however, because the patient was admitted to inpatient status from the ED at 11 p.m. and I didn't see him until the next calendar date, that would not be appropriate in this scenario.

A

Actually, CPT defines hospital admission as the first encounter between the physician and the patient at the site of service, regardless of the calendar date the patient becomes an inpatient. In this case, the patient was assigned to inpatient status at 11 p.m., but you did not see him until the following morning. You then discharged the patient later that day, resulting in a same-day admission/discharge service, which should be reported with a code from the series 99234-99236.

Assessing older drivers

Q

How should I bill for a visit to determine whether an elderly patient should continue to drive?

A

If your patient is covered by Medicare and the visit is prompted by specific symptoms or complaints, you should report the appropriate evaluation and management (E/M) code. Because counseling will likely be the predominant service in this encounter (i.e., accounting for more than 50 percent of the total face-to-face time), be sure to document your time and the counseling you provided. This will allow you to select the level of service based on time rather than key components.

If you provide additional services as part of your assessment, such as a health risk assessment (99420), muscle and range of motion testing (95831), visual function screening (99172) or screening test of visual acuity (99173), you can bill Medicare for these separately.

For a patient who is not experiencing symptoms, you should bill a code from the preventive medicine, individual counseling series (99401-99404). In this situation, Medicare will not cover the assessment services previously mentioned because there are no symptoms or illness to establish medical necessity.

Tdap injections

Q

What is the appropriate code for a Tdap injection?

A

The CPT code for a Tdap injection, which is a combination vaccine consisting of tetanus toxoid, diphtheria toxoid and acellular pertussis vaccine, is 90715. To bill for the administration of the vaccine, use 90465-90466 or 90471-90472. You may report preventive services or other significant, separately identifiable E/M services provided on the same date as the vaccine by appending modifier −25 to the E/M code.

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.

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